Deck 11: Medical Records

Question 1

The medical record is important to a health care facility because it ___________.

A) is a legal document
B) is a record of the care and treatment rendered to caregivers
C) is financially unnecessary
D) provides a planning tool for patient care

Answer 1

D

Question 2

The medical record must be ___________.

A) complete and accurate
B) legible and inaccurate
C) available solely to those conducting research
D) available basically for billing purposes

Answer 2

A

Question 3

The Privacy Act of 1974 was enacted to ___________.

A) safeguard the privacy of healthcare professionals
B) provide a backup for state records
C) provide individuals with legal access to federal records
D) safeguard individual privacy and discourage misuse of federal records

Answer 3

D

Question 4

The effective and efficient delivery of patient care requires that an organization determine its information needs. Organizations that do not centralize their information needs will often suffer from ___________.

A) centralized and organized databases
B) scattered databases
C) consistent reports
D) efficiency in the use of economic resources

Question 5

The admission record does not generally provide ___________.

A) the patient's age
B) the patient's address
C) the patient's sexual preferences
D) the patient's marital status, religion, and health insurance

Question 6

Ownership of the medical record resides with ___________.

A) the provider
B) legal counsel
C) patient
D) physician rendering treatment

Question 7

The Privacy Act of 1974 provides that ___________.

A) the privacy of individual information is not affected by the collection, maintenance, use, and dissemination of personal information by Federal agencies
B) the increasing use of computers and sophisticated information technology, while essential to the efficient operations of the Government, has in no way harmed individual privacy that can occur from the collection, maintenance, use, or dissemination of personal information
C) the opportunities for an individual to secure employment, insurance, and credit; his right to due process; and other legal protections have been found safe by the misuse of certain information systems
D) the right to privacy is a personal and fundamental right protected by the Constitution of the United States

Question 8

Patients have a legally enforceable right to ___________.

A) the information contained in their caregivers medical records
B) access the information contained in their medical records
C) review and obtain copies of their records, X-rays, and laboratory and diagnostic tests
D) access to information maintained or possessed by a few health care organizations

Question 9

A patient's medical record may not be released ___________.

A) to health insurance companies for reimbursement purposes
B) to health insurance companies in order to process health claims
C) because a person is in the public spotlight (e.g., movie star)
D) for criminal investigative work

Question 10

The length of time medical records must be retained ___________.

A) is set by insurance carriers
B) is set by federal law
C) is the same in all states
D) can vary from state to state

Question 11

Health care organizations undergoing computerization must ___________.

A) develop a disaster recovery plan (e.g., provide for emergency power systems and backup files), provide for data security, design an effective system, and seek input from end users
B) determine direct computer ease of access for patients
C) select the least expensive hardware
D) determine building services ease of access to patient information

Question 12

The advantages of computer systems ___________.

A) have yet to be developed
B) play an ever-decreasing role in the education process
C) include timely retrieval of demographic information, consultant reports, and test results
D) no longer allows for computer-generated prescriptions

Question 13

The persistent failure to conform to a medical staff rule requiring physicians to complete records promptly can be the basis for ___________.

A) limitations placed on or suspension of medical staff privilege
B) assuring medical staff privileges
C) sanctions by the planning board
D) granting surgical privileges

Question 14

The integrity and completeness of the medical record can be important in reconstructing the events surrounding an alleged negligence or criminal act in the care of a patient. The medical record can ___________.

A) aid police investigations
B) aid in determining the cause of death
C) provide information for workers' compensation cases and personal injury proceedings
D) all of the above

Question 15

The Health Insurance Portability and Accountability Act of 1996 provides that ___________.

A) patients must be able to access their record and request correction of errors
B) patients must be informed as to how their personal information will be used
C) patient information cannot be used for marketing purposes without the explicit consent of the involved patients
D) all of the above

Question 16

The HIPAA security provisions took effect April 20, 2005. HIPAA defines the three segments of security safeguards for compliance as ___________.

A) administrative, physical, and technical
B) administrative, physical, and emotional
C) administrative, technical, and total
D) physical, technical, and tertiary

Question 17

Rewriting record entries by a nurse ___________.

A) is a good practice even after the patient has been discharged
B) is well-publicized as the right thing to do
C) can illustrate how conscientious the caretaker is, especially during a lawsuit
D) can cast doubt on the accuracy of other medical record entries

Question 18

Medical record entries should ___________.

A) be written within seven days of observing a patient's deteriorating condition
B) be written within 21 days of observing a patient's deteriorating condition
C) be legible
D) not provide too much clarity

Question 19

When making changes to a patient's record, ___________.

A) erasures and correction fluid should be used to cover up entries
B) covering up mistakes is not considered tampering.
C) a single line should be drawn through a mistaken entry and the correct information should be entered, signed, and dated
D) the correction is signed, but the inclusion of a date is unnecessary

Question 20

The following should be written in a patient's medical record:

A) long, defensive, or derogatory notes
B) facts pertinent to the patient's care
C) complaints or emotional comments about other caregivers
D) emotional comments and extraneous remarks

Question 21

Progress notes should describe the patient's ___________

A) symptoms or condition being addressed, the treatment rendered, the patient response, and patient's status at the time treatment is discontinued
B) treatment rendered but not the patient's response
C) patient's status 3 weeks after discharge
D) observation of the physician

Question 22

The process of facilitating the flow of information within and among departments and caregivers is ___________.

A) treatment planning
B) computerization of financial records
C) digitized clinical data
D) information management

Question 23

Peer review documents are

A) discoverable in all states
B) available to all hospital employees
C) generally exempt from discovery
D) available for public review

Question 24

Falsification of medical records is grounds for a ___________.

A) negligent act
B) criminal indictment
C) tort
D) contract dispute

Question 25

Persistent failure of a physician to complete his or her medical records can lead to ___________.

A) promotion
B) suspension of medical staff privileges
C) breach of confidentiality
D) improved reimbursement from patience insurance carriers

Question 26

Ordinary business documents are ___________.

A) considered privileged
B) generally protected from discovery by state statutes
C) not protected as privileged communications by state statutes
D) are considered strictly confidential information and their contents cannot be exposed with some exceptions in a court of law

Question 27

Charting by exception requires ___________.

A) charting significant changes in a patient's condition
B) writing copious notes in a patient's medical record
C) detailed charting in a patient's record from admission to discharge
D) none of the above